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State of California Department of Resources Recycling and Recovery CalRecycle 169 (Rev. 12/17) (CalRecycle) ENFORCEMENT AGENCY NOTIFICATION Enforcement Agency: Completion of this form is not required y regular' ,how ver, ihg Official Use Only SWIS Number: County: Date Received: L GENERAL INFORMATION Operation Name: . om Address: cNd S City: S State: Zip: 15 Phone: Fax: Operator Name: 0 Address: fj City: State: Zip: Phone: 20q (.0jSr- I—j— Fax: Land Owner: v °� Address: 7 %6 ti State: Zip: J G Phone: 3 _ Fax It. OPERATION INFORMATION Authorizing Eligibility (state Section of 14 CCR Division 7, Chapter 3, 3.1 or 3.2): See back for more details Type(s) of Waste/Material Handled: �'1Gt1 L re corwn wask. CO -h in Ll JCL Volume of Waste/Material Handled: r5,DOO—QS ovw NiardS Peak Loading: I 'aCo I] Cubic Yards or1ATons Annual Loading: I El Cubic Yards or l] Tons Days and Hours of Operation: �AYYI _ 1.4 h 1 Operation Acreage: Brief Description of the Operation: Cbmms-ua e lam+ C) -mug III. DOCUMENTATION OF LOCAL NOTIFICATION (check one and submit with EA Notification) ❑ Proof of Compliance with the California Environmental Quality Act (CEQA).. ❑ Correspondence from the local planning department that compliance with CEQA is not required for the operation to obtain local land use approval, ❑ Written notice to the local planning department of the operator's intent to commence operations. IV. OWNER/OPERATOR CERTIFICATION I hereby certify under penalty of perjury that the information provided is true and accurate to the best of my knowledge and belief. Signature of Land Owner: Date: 5 Signature of Operator: Date: Z/ provide the enforcement agency with the information required by 14 CCR 18103.1. • A separate Notification is required for each eligible operation. Please cite only one of the following Title 14 regulations when filling in the "authorizing eligibility" box of Notification Form CalRecycle 169: